Physical Examination and Assessment

Of The Newborn

APGAR SCORING SYSTEM
Developed in 1950s Cardiopulmonary status Dr. Virginia Apgar 1 minute after birth 5 minutes after birth 5 parameters A = Appearance (skin color) P = Pulse (heart rate) G = Grimace (reflex irritability) A = Activity (muscle tone) R= Respiration
‡ (respiratory effort)

Criteria for Apgar Scoring
Category
Heart ate espiratory Effort scle Tone eflex Irrita ility Skin Color

Points
A sent A sent Flacci , Li p Unresponsive Cyanosis

1 Point
Un er 1 Irreg lar, Weak So e flexion

2 Points
ver 1 Crying, igoro s Active flexion, goo otion

Fro n/ ri ace Active otion/ sti lation cry, cf. sneeze Acrocyanosis Co pletely Pink

APGAR SCORING SYSTEM
One Minute Score
‡ Identifies need for immediate intervention ‡ Score 2 0r less = immediate resuscitation ‡ Score 3 to 6 = some assistance, usually stimulation, suctioning, oxygen ‡ Score 7 or more = routine care and observation

APGAR SCORING SYSTEM
Five Minute Score
‡ ‡ ‡ ‡ Assess infant·s recovery from depression Also assess effectiveness of intervention Score 7 to 10 = Few, if any, supportive measures Score 4 to 6 = Mild to moderate asphyxia; suctioning, oxygenation, mech ventilation ‡ Score 0 to 3 = Full cardiopulmonary resuscitation

SILVERMAN SCORE
Looks at level of respiratory distress Scoring in 5 areas, range from 0 to 2
‡ pper chest movement
² Synchronized = 0 ² Lag of chest on inspiration = 1 ² Seesaw movement upper chest = 2

‡ Lower chest movement

SILVERMAN SCORE- continued SCORELower chest movement (continued)
‡ No retractions = 0 ‡ Retractions - just visible = 1 ‡ Marked retractions = 2

Xiphoid retractions
‡ No retractions = 0 ‡ Retractions - just visible = 1 ‡ Marked retractions = 2

SILVERMAN SCORE- continued SCOREDilation of nares
‡ None = 0 ‡ Minimal dilation = 1 ‡ Marked dilation = 2

Expiratory Grunt
‡ None = 0 ‡ eard only w/ stethoscope = 1 ‡ eard w/ naked ear = 2

SILVERMAN SCORE- continued SCOREScoring Scale
‡ 0 to 3 = no respiratory distress to mild distress ‡ 4 to 6 = moderate respiratory distress ‡ 7 to 10 = severe respiratory distress

ESTIMATION OF GESTATIONAL AGE
Dubowitz Score
‡ Dr. Dubowitz and co-workers (Early 1970s) co‡ 10 external characteristics ‡ 11 Neuromuscular signs

New Ballard Score (NBS)
‡ Increase accuracy in very low birthweight ‡ 7 physical & 6 neurologic criteria
² No lifting patient ; intubated & monitored

ESTIMATION OF GESTATIONAL AGE
NBS - continued Each category scored from -1 to +4 or +5 Physical Maturity
‡ Skin - transparent to leathery, cracked ‡ Lanugo - none to mostly bald, upper back only ‡ Plantar Surface - little or no creases to creases over entire sole ‡ Breast - imperceptible to full areola

ESTIMATION OF GESTATIONAL AGE
NBS - continued
‡ Eye/Ear - lids fused, pinna flat to well curved pinna, thick cartilage ear stiff ‡ Genitals male -scrotum flat, smooth to testes pendulous ‡ Genitals female - clitoris prominent, labia flat to majora cover clitoris and minora

ESTIMATION OF GESTATIONAL AGE
NBS - continued Neuromuscular Maturity
‡ Posture & extremities / muscle tone: ‡ Posture - hypotonic w/ arms & legs extended to arms & legs flexed w/ recoil ‡ Square indow (wrist) - greater than 90* to 0* ‡ Arm Recoil - none to full recoil w/ angle < 90* ‡ Knee Joint Angle (popliteal) - from 180* to less than 90*

ESTIMATION OF GESTATIONAL AGE
NBS - continued Scarf Sign - no resistance to full resistance eel to Ear - no resistance w/ little or no knee flexion to significant resistance with flexed knee

ESTIMATION OF GESTATIONAL AGE
NBS - continued
-10 -5 0 5 10 15 20 20 wks 22 wks 24 wks 26 wks 28 wks 30 wks 32 wks

SCORING SYSTEM
25 30 35 40 45 50 34 wks 36 wks 38 wks 40 wks 42 wks 44 wks

ESTIMATION OF GESTATIONAL AGE
- continued: External Criteria
Vernix
‡ grayish white cheeselike substance ‡ composed of
² sebaceous gland secretions ² lanugo ² shed epithelial cells

‡ Preterm covered ‡ Term has very little, only in body creases ‡ Post-term has none Post-

Nails
‡ present and cover nail bed all ages ‡ may be especially long in post-term post-

‡ amount is age related

Growth Assessment
Colorado intrauterine growth curve

Plot gestational age against:
‡ Birth weight ‡ Length ‡ ead circumference ‡ Data from Colorado infants 1948 to 1961

Colorado intrauterine growth curve
Score between 10th and 90th percentiles = AGA Score below the 10th percentile = SGA Score above the 90th percentile = LGA

VITAL SIGNS

RESPIRATORY RATE EART RATE

BLOOD PRESS RE TEMPERAT RE

RESPIRATORY RATE
Normal = 30 to 60, variable Periodic Breathing = respiration interrupted by short periods of apnea, up to 10 seconds, not associated w/ other abnormalities
‡ Common in preterm infants

Very little chest wall movement Count for full minute

HEART RATE
Normal newborn = 110 to 160 Determined by auscultation Transient increases w/ agitation Persistent tachy associated w/ congenital heart defects Brady associated w/ significant apnea Apical impulse - normal vs. abnormal location

BLOOD PRESS RE
Normal Ranges:
‡ Low birth weight = 50/35 mmHg. ‡ Mid b.w. above 2000 gm. = 60/35 mmHg. ‡ High b.w. above 3000 g. = 65/40 mmHg.

Assessed with doppler and cuff Peripheral pulses for indirect assessment
‡ - brachial - radial - femoral

TEMPERAT RE
Normal core = somewhat variable Rectum is best assessment of core Axilla, usually lower but may be falsely high Skin Temp
‡ Allow continual measurement ‡ Pt. Care not interfered ‡ Maintained about 36.5 degrees (C) ‡ Minimize O2 consumption

OTHER CLINICAL ASSESSMENTS
SIGNS OF RESPIRATORY DISTRESS

5 Common
‡ ‡ ‡ ‡ ‡ Tachypnea Cyanosis Nasal Flaring - Silverman score Expiratory Grunting - Silverman score Retractions - Partially Silverman score

RESPIRATORY DISTRESS -continued
Tachypnea = RR > 60
‡ Over 50 should increase suspicion ‡ Full minute assessment

Cyanosis = bluish discoloration
‡ Local vs. General ‡ Central
² Involves mucous membranes ² Indicates excessive unsaturated hemoglobin

RESPIRATORY DISTRESS -continued
‡ Central Cyanosis - continued
² In excess of 5 g / dl ² Presence usually indicative of PO2 < 40 mmHg ² Slight drop in PO2 yields dangerous sharp decline in hemoglobin saturation, O2 carrying capacity ² Anemic baby may have no cyanosis w/ extreme hypoxemia

‡ Acrocyanosis - hands & feet
² common in newborns

RESPIRATORY DISTRESS -continued
Retractions = inward movement of chest wall
‡ ‡ ‡ ‡ ‡ Intercostal = between ribs Supraclavicular = above clavicles Subcostal = below rib margins Suprasternal = top margins of sternum Xiphoid = bottom margins at xiphoid process

RESPIRATORY DISTRESS -continued
Apnea = periods of no respiration for at least 20 seconds Or periods of absence of respiration accompanied by bradycardia (HR < 100)

Chest Auscultation
Rales
‡ ´cracklesµ ‡ short, interupted sounds ‡ usually during inspiration ‡ associated with
² HMD ² Pulmonary Edema ² Pneumonia

Rhonchi
‡ changes in pitch ‡ narrowing of airways
² ² ² ² secretions swelling foreign matter smooth muscle spasm

‡ ´Courseµ = low pitch ‡ ´ heezeµ = high pitch

Head, Face, & Neck Exam
Assessment of Congenital Anomalies Head
‡ Shape & Size
² Compression during birth - self correcting

‡ Occipital Frontal Circumference (OFC) ‡ Ears
² Shape, Size, Position, Presnce of ear canals

Head, Face, & Neck Exam - cont.
Face
‡ Eyes
² Size -Shape -Position -Patency of Nasal Pasages -Size of tongue & jawbone

‡ Nose
² Size -Shape

‡ Mouth
² Lips -Hard/Soft Palate

Head, Face, & Neck Exam - cont.
Neck Inspected for;
‡ Range of motion ‡ Goiter ‡ Presence of cysts

ABDOMEN, SKIN, EXTREMETIES
Abdomen
‡ Protrusion of abdominal contents ‡ Appearance & position of umbilicus

Skin
‡ Pigmentation, Rashes, Bruising, nusual ‡ Jaundice

ABDOMEN, SKIN, EXTREMETIES
Extremeties - fingers & toes
‡ Position ‡ Size ‡ Number

Hands & Feet
‡ Color

Pulses
‡ Brachial & Femoral

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